There is a well-established association between health, social and environmental factors, many of which are amenable to legal interventions.1 2 Legal issues affect health in multiple ways by structuring, perpetuating, and mediating the social determinants of health found in the dynamic interconnections between the medical, social, and legal arenas.3 Examples include legal issues related to housing (such as the threat of eviction or environmental health hazards due to substandard housing), financial disputes, domestic violence, and other forms of physical or sexual abuse.4 Medico-socio-legal collaboration, from a medical perspective, refers to a health-related case with social and legal implications to the extent that an attending doctor, after eliciting the patient’s history and conducting a physical examination, seeks input from social workers or requests investigation by law enforcement agencies to benefit the patient and especially to improve their health outcomes.5 In various settings, notably Canada, the United Kingdom, and the United States, primary care practitioners have brought legal advice directly to their patients through medico-socio-legal partnerships, to help address legal issues that have been identified in primary care settings as deleterious to patient health.6

Legal services offered in the primary care setting are typically provided in partnership with a full-service legal aid clinic, rather than by having a lawyer on staff. This is because the legal advice given is by nature often complex and specialised, and also because of the privileged nature of the client–legal service provider relationship. These services are often most effectively offered in the context of team-based care, where a multidisciplinary group of professionals works together to address patients’ needs in a more holistic way, rather than focusing solely on their medical conditions, and to look at underlying social and legal issues that are affecting their health. Examples of well-established legal services in primary care include the legal clinic at McMaster Family Practice7 and the Health Justice Program offered by St Michael’s Academic Family Health Team, both in Toronto, Canada.8 Colvin et al9 reported that the engagement of social workers significantly enhanced the effectiveness of the existing medico-legal partnership.

In Hong Kong, there are a number of medical and social collaboration programmes linking public hospitals and non-governmental organisations (NGOs) to serve the population. An example is the Jockey Club End-of-Life Community Care Project, which specialises in end-of-life care for older citizens.10 However, the integration of legal advice into the primary care setting as a form of medico-social collaboration has thus far remained unexplored. Based on international experience, and given the high levels of poverty and social deprivation in the city, along with evidence of their deleterious effects on health, it is likely that there are issues that could be amenable to amelioration through legal advice. What remains unknown is which legal issues would arise if such a service were made available in the primary care setting in Hong Kong, and the extent to which a service would be appreciated by patients.

Our team, comprising family physicians from the Department of Family Medicine and Primary Care, The University of Hong Kong, along with experts in social work and legal training, conducted four sessions of medico-socio-legal consultations at the Kwai Tsing District Health Centre and the Kowloon City District Health Centre Express in April and May 2024. We began with a talk on common medico-socio-legal issues such as chronic diseases, mental health, and advance directives, followed by individual consultations with experts from the three fields. In total, 37 clients (32 female and 5 male) were recruited by two collaborating NGOs—the Lok Sin Tong Benevolent Society Kowloon and the Kwai Tsing Safe Community and Healthy City Association—to attend the individual consultations.

Taken together, their concerns reflected the core values of family medicine, namely, that biopsychosocial issues are intertwined. Examples included financial difficulties and marital concerns, either resulting from health conditions or contributing to them; obstacles in accessing Mandatory Provident Fund investments due to health issues; caregiver stress in addition to chronic illness; litigation involving inheritance and housing issues; transfer of legal property rights; and disputes among family members. In follow-up calls, most clients reported experiencing both physical and psychological relief from having their concerns heard and addressed in a one-stop “clinic” within the community setting, where experts from all three fields provided coordinated advice. In one case, a client who had been embroiled in a civil legal dispute for years continued to express anger and health-related concerns during follow-up, prompting our team to consider longer-term needs for medico-socio-legal collaboration in the primary care setting.

After the consultations, the majority of clients affirmed that the sessions had strengthened their physical and mental health. They expressed hope to see more joint clinics of this nature within the primary care setting. As service providers, we found that it was both feasible and effective to implement a medico-socio-legal clinic to alleviate patients’ physical and psychological suffering by providing comprehensive information from relevant experts to address their problems. The unique feature of our initiative was the integration of expert input from medical, social, and legal perspectives.

The overarching aim of this initiative was to raise awareness of the health impact of legal issues, acknowledge the interactions between social determinants and health, and propose interventions that promote health justice within Hong Kong’s primary healthcare system. We seek to highlight the current service gap and explore the possibility of establishing sustainable medico-socio-legal clinics in the primary healthcare setting. Cross-sector collaboration in primary care can be strengthened by identifying opportunities and resources for the government or NGOs in the public sector—and for newly established District Health Centres supporting private healthcare providers—to develop such joint clinics and offer improved services.

Concept or design: WCW Wong, JE Parry.
Acquisition of data: WCW Wong, ETY Tse, P Lu, CLW Chan, A Lee, KW Tong.
Drafting of the manuscript: JE Parry, ETY Tse.

All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

All authors have disclosed no conflicts of interest.

The authors acknowledge administrative support for client recruitment and provision of service venues by the Lok Sin Tong Benevolent Society Kowloon and the Kwai Tsing Safe Community and Healthy City Association, in their respective District Health Centre Express in Kowloon City and District Health Centre in Kwai Chung. Special thanks to Mr Eugene KY Chan for providing administrative assistance to the project and contributing to the initial draft of this article.

The content of this editorial has been presented as oral presentation in the 26th WONCA Asia Pacific Regional Conference (WONCA APR 2025) in Busan, Republic of Korea, 24-27 April 2025.

This editorial received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. Gottlieb L, Hessler D, Long D, Amaya A, Adler N. A randomized trial on screening for social determinants of health: the iScreen study. Pediatrics 2014;134:e1611-8. Crossref

2. Klein MD, Beck AF, Henize AW, Parrish DS, Fink EE, Kahn RS. Doctors and lawyers collaborating to HeLP children—outcomes from a successful partnership between professions. J Health Care Poor Underserved 2013;24:1063-73. Crossref

3. Gostin LO, Monahan JT, Kaldor J, et al. The legal determinants of health: harnessing the power of law for global health and sustainable development. Lancet 2019;393:1857-910. Crossref

4. Sandel M, Hansen M, Kahn R, et al. Medical-legal partnerships: transforming primary care by addressing the legal needs of vulnerable populations. Health Aff (Millwood) 2010;29:1697-705. Crossref

5. Law Insider. Medico-Legal definition. Available from: https://www.lawinsider.com/dictionary/medico-legal. Accessed 17 Jul 2024.

6. Parry J, Vanstone M, Grignon M, Dunn JR. Primary care-based interventions to address the financial needs of patients experiencing poverty: a scoping review of the literature. Int J Equity Health 2021;20:219. Crossref

7. Agarwal G, Pirrie M, Edwards D, et al. Effect of a legal clinic program within an urban primary health care center on social determinants of health: a program evaluation. J Prim Care Community Health 2024;15:21501319241245849. Crossref

8. Drozdzal G, Shoucri R, Macdonald J, Radford K, Pinto AD, Persaud N. Integrating legal services with primary care: The Health Justice Program. Can Fam Physician 2019;65:246-8.

9. Colvin JD, Nelson B, Cronin K. Integrating social workers into medical-legal partnerships: comprehensive problem solving for patients. Soc Work 2012;57:333-41. Crossref

10. Jockey Club End-of-Life Community Care Project. “Life Rainbow” End-of-life Care Services. Medical Social Collaboration Approach in End-of-Life Care: Experience from a Multidisciplinary Program. Available from: https://foss.hku.hk/jcecc/wp-content/uploads/2020/09/P4.2_Ying-Ying-HO_Revised.pdf. Accessed 17 Jul 2024.

Hong Kong’s healthcare system is at a critical juncture. An ageing population, rising prevalence of chronic diseases, persistent disparities between the public and private sectors, and rapid advancements in medical technology are among the challenges calling for a new, coordinated, and evidence-based approach to healthcare service development. The Government’s initiative to establish the Institute for Medical Advancement and Clinical Excellence (IMACE) on 8 May 2025 represents a significant step forward in addressing these complex issues.1

The IMACE is an independent, professional platform funded by the Health Bureau, with a mandate to provide guidance on medical practice and healthcare delivery. Its formation responds to several pressing challenges: unwarranted variations in clinical care, the need for timely evaluation of new medical technologies, and the imperative to improve health outcomes across all sectors of our population in a sustainable manner.

To ensure a diverse coalition that reflects the views and experiences of different sectors of our healthcare system, seven institutions were invited to serve as Founding Members (Box). Together with a Convenor nominated by the Hong Kong Academy of Medicine, they form the Governing Board that oversees the institute’s functioning and determines its strategic directions. A Secretariat housed under the Hong Kong Academy of Medicine provides administrative support.

The primary mission of IMACE centres on developing and disseminating evidence-based recommendations to guide clinical practice and healthcare policy. These recommendations, collectively termed IMACE Recommendations, may encompass clinical practice guidelines (CPG), clinical protocols, evaluation of the efficacy and cost-effectiveness of medical options, and standards for service quality and efficiency. During the initial phase we are prioritising the development of CPG which may cover, but are not limited to, the use of medicines, diagnostic technologies, medical devices, digital technologies, and interventional procedures in primary, secondary, and community care. Guideline development will adhere to IMACE’s Core Principles of being “evidence-based, impartial, patient-centred, collaborative, and innovative”2 and follow internationally recognised methodologies where appropriate, while remaining responsive to Hong Kong's specific healthcare context.3

A number of factors will be considered by the Governing Board when identifying clinical topics for guideline development. These include: whether there is significant and unwarranted variation in clinical practice; whether the guideline is likely to reduce avoidable illness, care burden, significant morbidity and/or premature mortality; whether the guideline is likely to enhance service quality and efficiency; whether there is a sufficient volume of reliable evidence proportionate to the context of the topic area, and so on.4 To expedite the guideline development process, reference may be made to CPG already published by local or overseas professional organisations. An operational framework for prioritisation, implementation, and quality assurance is under development.

The IMACE CPGs, defined as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances”,5 are applicable to healthcare professionals and providers across the public and private sectors in Hong Kong. They are advisory in nature and intended to support clinical decision-making, not to replace professional expertise and individual clinical judgement. The IMACE CPG are also intended to facilitate the safe, responsible, and cost-effective application of new technologies, not to restrict their adoption. Healthcare professionals and providers are encouraged to follow IMACE CPG where appropriate; any departure from these guidelines should be supported by good clinical reasons.2

Another focus of our work is public education. The IMACE recognises that high-quality healthcare requires informed patients who can actively participate in their care decisions. However, as medical practices become increasingly sophisticated, patients may find it difficult to handle the large amount of complex information presented by their doctors or available online. To address this, we plan to develop patient education materials that explain the principles of clinical research and medical evidence in clear, accessible language. These resources aim to improve health literacy without oversimplifying information, facilitate constructive doctor-patient communication, and empower patients to make informed and personalised decisions.

The IMACE is an unprecedented collaboration, bringing together institutions that have traditionally operated independently. Through alignment of shared standards of care while respecting the diversity of our healthcare landscape, this cooperative model enables us to address systemic challenges that individual organisations could not tackle alone. The IMACE is well-positioned to serve as a catalyst for meaningful and lasting improvements in Hong Kong’s healthcare system and, in time, to play an important role in shaping the future of medicine in the region. The journey ahead will require the ongoing engagement of and support from all stakeholders, from frontline clinicians to hospital administrators, policymakers, and patients themselves. It is a daunting task, but also a worthwhile and exciting one.

All authors contributed equally to the conception, preparation, and editing of the manuscript. All authors approved the final version for publication and take responsibility for its accuracy and integrity.

All authors have disclosed no conflicts of interest.

1. The Hong Kong SAR Government. Government welcomes formal establishment of Institute for Medical Advancement and Clinical Excellence today. 8 May 2025. Available from: https://www.info.gov.hk/gia/general/202505/08/P2025050800676.htm?fontSize=1. Accessed 8 May 2025.

2. Constitution of the Institute for Medical Advancement and Clinical Excellence (IMACE). Hong Kong: Institute for Medical Advancement and Clinical Excellence; 2025.

3. National Institute for Health and Care Excellence. Developing NICE guidelines: the manual. NICE process and methods. 31 October 2014 (last updated 29 May 2024). Available from: https://www.nice.org.uk/process/pmg20/chapter/introduction. Accessed 1 May 2025.

4. National Institute for Health and Care Excellence. NICE-wide topic prioritisation: the manual. NICE process and methods. 29 May 2024 (last updated 31 March 2025). Available from: https://www.nice.org.uk/process/pmg46. Accessed 1 May 2025.

5. Institute of Medicine, Committee to Advise the Public Health Service on Clinical Practice Guidelines. Clinical Practice Guidelines: Directions for a New Program. US: Washington DC, National Academies Press; 1990.

Timely treatment is the primary strategy to protect kidney health, prevent disease progression and related complications, reduce cardiovascular risk, and prevent premature kidney-related and cardiovascular mortality.1 2 3 International population assessments show low awareness and detection of kidney disease, along with substantial gaps in treatment.2 People with kidney failure universally express a preference for having been diagnosed earlier in their disease trajectory, which would allow more time for educational, lifestyle, and pharmacological interventions.4 Therefore, increasing knowledge and implementing sustainable solutions for the early detection of kidney disease to protect kidney health are public health priorities.2 3

Chronic kidney disease (CKD) is prevalent, affecting 10% of the global population—over 700 million people.5 Nearly 80% of people with CKD live in low-income countries (LICs) and lower-middle-income countries (LMICs), and approximately one-third of the known affected population resides in China and India alone.5 6 The prevalence of CKD increased by 33% between 1990 and 2017.5 This rising trend is driven by population growth, ageing, and the obesity epidemic, which contribute to higher rates of two major CKD risk factors: type 2 diabetes mellitus (T2DM) and hypertension. Additionally, risk factors beyond cardiometabolic conditions add to the growing burden of kidney disease. These include social deprivation, pregnancy-related acute kidney injury, preterm birth, and escalating environmental threats such as infections, toxins, climate change, and air pollution.5 7 These threats disproportionately affect people in LICs and LMICs.8

Undetected and untreated CKD is more likely to progress to kidney failure and cause premature morbidity and mortality. Globally, more people died in 2019 of cardiovascular disease attributed to reduced kidney function (1.7 million people) than the number who died of kidney disease alone (1.4 million).5 Chronic kidney disease is expected to become the fifth most common cause of years of life lost by 2040, surpassing T2DM, Alzheimer’s disease, and road injuries.9 The rising mortality associated with kidney disease is particularly remarkable compared with other non-communicable diseases—such as cardiovascular disease, stroke, and respiratory illness—which are projected to exhibit declining mortality rates.8 Even in its early stages, CKD is associated with multi-system morbidity that diminishes quality of life. Notably, mild cognitive impairment is linked to early-stage CKD; early detection and treatment could slow cognitive decline and reduce the risk of dementia.10 Chronic kidney disease in children has profound additional consequences, threatening growth and cognitive development, with lifelong health and quality of life implications.11 12 The number of people requiring kidney failure replacement therapy—dialysis or transplantation—is anticipated to more than double from 2010 to 2030, reaching 5.4 million.13 14 Kidney failure replacement therapy, particularly haemodialysis, remains unavailable or unaffordable for many in LICs and LMICs, contributing to millions of deaths annually. Although LICs and LMICs comprise 48% of the global population, they represent only 7% of the treated kidney failure population.15

Testing individuals at high risk for kidney disease (case-finding) minimises potential harms and false-positive results compared with general population screening, which should only be considered in high-income countries (HICs). Testing limited to those at increased risk of CKD would still encompass a large proportion of the global population. Moreover, targeted case-finding in patients at high risk of CKD is not optimally performed, even within HICs. Approximately one in three people globally have diabetes and/or hypertension. There is a bidirectional relationship between cardiovascular disease and CKD—each increases the risk of the other. Both the American Heart Association and the European Society of Cardiology recommend testing individuals with cardiovascular disease for CKD as part of routine cardiovascular assessments.1 16

Other CKD risk factors include a family history of kidney disease (eg, APOL1-mediated kidney disease, which is common among individuals of West African ancestry), prior acute kidney injury, pregnancy-related kidney conditions (eg, pre-eclampsia), malignancy, autoimmune disorders (such as systemic lupus erythematosus and vasculitis), low birth weight or preterm birth, obstructive uropathy, recurrent kidney stones, and congenital anomalies of the kidney and urinary tract (Fig 1).3 Social determinants of health strongly influence CKD risk, both at individual and national levels. In LICs and LMICs, heat stress among agricultural workers is thought to contribute to CKD of unknown aetiology—an increasingly recognised and major global cause of kidney disease.17 Additionally, envenomations, environmental toxins, traditional medicines, and infections (such as hepatitis B or C, HIV, and parasitic diseases) warrant attention as risk factors, particularly in endemic regions.18 19

Conceptually, there are three levels of CKD prevention. Primary prevention aims to reduce the incidence of CKD by treating risk factors; secondary prevention focuses on slowing disease progression and reducing complications in those with diagnosed CKD; and tertiary prevention seeks to improve outcomes in people with kidney failure by enhancing management, such as through improved vaccination coverage and optimised dialysis delivery.20 Primary and secondary prevention strategies can incorporate the eight golden rules for promoting kidney health: maintaining a healthy diet, ensuring adequate hydration, engaging in physical activity, monitoring and controlling blood pressure, monitoring and controlling blood glucose levels, avoiding nicotine, avoiding regular use of non-steroidal anti-inflammatory drugs, and targeted testing for those with risk factors.21 Five of these rules are identical to Life’s Essential 8—guidelines for maintaining cardiovascular health—which also include achieving a healthy weight, getting adequate sleep, and managing lipid levels.22 Early detection efforts are a form of secondary prevention that involves protecting kidney health and reducing cardiovascular risk.

Globally, early detection of CKD remains rare, inconsistent, and less likely in LICs or LMICs. Currently, only three countries have a national programme for actively testing at-risk populations for CKD, and a further 17 countries perform such testing during routine healthcare encounters.23 Even in HICs, albuminuria is not assessed in more than half of individuals with T2DM and/or hypertension.24 25 26 Startlingly, a diagnosis of CKD is often absent even among those with documented reduced kidney function. A study conducted in HICs showed that 62% to 96% of individuals with laboratory evidence of CKD stage G3 had no recorded diagnosis of CKD.27

We recommend that healthcare professionals perform the following tests for all risk groups to assess kidney health (Fig 2 28):

a) Blood pressure measurement: Hypertension is the most prevalent risk factor for kidney disease worldwide.3 29 30
b) Body mass index: Obesity is epidemiologically associated with CKD risk, both indirectly (via T2DM and hypertension) and directly, as an independent risk factor. Visceral adiposity contributes to monocyte-driven microinflammation and increased cardiometabolic kidney risk.3 29 30
c) Testing for diabetes: Assessment with glycosylated haemoglobin, fasting blood glucose, or random glucose should be part of kidney health screening because T2DM is a common risk factor.3 29 30
d) Evaluation of kidney function: Serum creatinine should be used to estimated glomerular filtration rate (eGFR) in all healthcare settings.3 Glomerular filtration rate should be calculated using a validated, race-free equation appropriate for the specific country or region and age-group.3 In general, eGFR <60 mL/min/1.73 m² is considered the threshold for CKD in adults and children; a threshold of <90 mL/min/1.73 m² can be regarded as ‘low’ in children and adolescents over the age of 2 years.3 A limitation of creatinine-based eGFR is its sensitivity to nutritional status and muscle mass, which can lead to overestimation in states of malnutrition or frailty.3 28 Thus, the use of both serum creatinine and cystatin C provides a more accurate estimate of eGFR in most clinical contexts. However, the feasibility of cystatin C testing is mainly limited to HICs because of assay availability and cost relative to creatinine testing.3 28 31
e) Testing for kidney damage (albuminuria): In both adults and children, a first morning urine sample is preferred for assessing albuminuria.3 In adults, the quantitative urinary albumin–creatinine ratio (uACR) is the most sensitive and preferred test.3 Analytical standardisation of urinary albumin is currently underway, which should eventually support global standardisation of uACR testing.32 In children, both the protein–creatinine ratio and uACR should be tested to identify tubular proteinuria.3 Semiquantitative albuminuria testing provides flexibility for point-of-care or home-based testing.33 To be considered useful, semiquantitative or qualitative screening tests should correctly identify >85% of individuals with a quantitative uACR of ≥30 mg/g.34 In resource-limited settings, urine dipstick testing may be used, with a threshold of +2 proteinuria or greater to reduce false positives and guide repeat confirmatory testing.35

In specific populations, the following considerations may apply:

f) Testing for haematuria: Haematuria is often overlooked in recent clinical practice guidelines, despite its importance as a risk factor (particularly for individuals at risk of glomerular disease, such as immunoglobulin A nephropathy).36
g) Baseline imaging: Imaging should be performed in individuals presenting with signs or symptoms of structural abnormalities (eg, pain and haematuria) to identify kidney masses, cysts, stones, hydronephrosis, or urinary retention. Antenatal ultrasound can detect hydronephrosis and other congenital anomalies of the kidney and urinary tract.
h) Genetic testing: With increasing access to genetic diagnostics, family cascade testing for CKD is indicated where there is a known hereditary risk of kidney disease.37
i) Occupational health screening: Individuals with occupational risk of developing kidney disease should be offered kidney function testing as part of workplace health programmes.
j) Post-donation surveillance: Kidney donors should be included in long-term follow-up programmes to monitor kidney health after donation.38

Screening for CKD aligns well with many of the World Health Organization (WHO)’s Wilson–Jungner principles.39 Early-stage CKD is asymptomatic; effective interventions—including lifestyle modification, interdisciplinary care, and pharmacological treatments—are well established.2 3 28 35 Several WHO Essential Medicines that improve CKD outcomes should be widely available, including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, statins, and SGLT2is (sodium-glucose co-transporter-2 inhibitors).2 40 Sodium glucose co-transporter-2 inhibitors alone are estimated to decrease the risk of CKD progression by 37% in individuals with and without diabetes.41 For a 50-year-old individual with albuminuria and non-diabetic CKD, this treatment could extend their healthy kidney function period from 9.6 to 17 years.42 These essential medicines slow progression to more advanced CKD stages and reduce cardiovascular hospitalisations, offering near-term cost-effectiveness—especially vital for LICs. Where available and affordable, the range of paradigm-shifting medications to slow CKD progression includes glucagon-like peptide-1 receptor antagonists, non-steroidal mineralocorticoid receptor antagonists, endothelin receptor antagonists, and specific disease-modifying drugs (eg, complement-inhibitors); these treatments herald an exciting new era for nephrology.

Considering the substantial healthcare costs associated with CKD—particularly those related to hospitalisation and kidney failure—effective preventive measures offer clear economic benefits for both HICs and LICs. Chronic kidney disease imposes enormous financial burdens on individuals, their families, healthcare systems, and governments worldwide. In the United States, CKD costs Medicare over US$85 billion annually.13 In many HICs and middle-income countries, 2% to 4% of national health budgets are allocated to kidney failure care alone. In Europe, healthcare costs related to CKD exceed those associated with cancer or diabetes.43 Reducing the global burden of kidney care would also yield important environmental benefits, including reductions in water usage and plastic waste, especially from dialysis.44 On an individual level, CKD costs are frequently catastrophic, particularly in LICs and LMICs, where the individuals often bear the majority of healthcare expenses. Only 13% of LICs and 19% of LMICs provide kidney failure replacement therapy coverage for adults.15 Each year, CKD causes an estimated 188 million people in LICs and LMICs to incur catastrophic healthcare expenditures.45

The most widely cited and studied incremental cost effectiveness ratio threshold for assessing screening interventions is US$<50 000 per quality-adjusted life year.46 When CKD prevalence is high, population-wide screening strategies may be considered in HICs.33 47 For example, in the United States, a recent Markov simulation model assessed population-wide CKD screening in adults aged 35 to 75 years with albuminuria. The model included treatment with SGLT2is, in addition to standard care with ACE inhibitors or angiotensin receptor blockers. The analysis indicated that such a screening approach would be cost-effective.47 Additionally, an evaluation of home-based, semiquantitative albuminuria screening in the general population in the Netherlands showed that it was cost-effective.33 Case finding—targeting higher-risk groups for CKD detection—offers a more efficient and cost-effective approach than mass or general population screening. It reduces costs and potential harms while increasing the true positive rate of screening tests.3 35 46 An alternative incremental cost-effectiveness ratio threshold, proposed by the WHO, suggests using a benchmark of less than 1 to 3 times the gross domestic product per capita per quality-adjusted life year to evaluate cost-effectiveness in LICs and LMICs.46 The recommended tests for detecting kidney disease are low-cost and minimally invasive, making them feasible across diverse healthcare settings. Basic tests, such as eGFR and uACR, are widely available. In contexts where quantitative testing for proteinuria is unavailable or unaffordable, the use of urine dipstick testing can substantially reduce costs.31

When coupled with effective interventions, early identification of individuals with kidney disease would yield benefits for patients, healthcare systems, governments, and national economies.45 Health and quality-of-life gains for individuals would lead to greater productivity—especially for younger people with more working years ahead—while improving developmental and educational outcomes in children and young adults. Individuals would also be less likely to face catastrophic healthcare expenses. Governments and healthcare systems would benefit from reduced CKD-related expenditures and lower cardiovascular disease costs. Economies would benefit from increased workforce participation. These benefits are especially crucial for lower-income countries, where the burden of CKD is greatest but the capacity to fund kidney care is most limited.

Structural barriers to widespread CKD identification and treatment include high costs, limited test reliability, and lack of health information systems to monitor CKD burden. These challenges are compounded by a lack of relevant government and healthcare policy, low levels of CKD-related knowledge and implementation among healthcare professionals, and limited public awareness of CKD and low perceived risk among the general population. Solutions for implementing effective interventions include integrating CKD identification into existing screening programmes, educating both the public and primary care professionals, and leveraging joint advocacy efforts from non-governmental organisations to focus health policy agendas on kidney disease. Any proposed solution must carefully balance the potential benefits and harms of screening and case-finding initiatives. Ethical considerations encompass resource availability (such as trained healthcare workers and access to medicines), affordability of testing and treatment, and the psychological impact of false positives or negatives, including potential anxiety for patients and their families.48

Successful screening and case-finding programmes require adequate workforce capacity, robust health information systems, reliable testing equipment, and equitable access to medical care, essential medicines, vaccines, and medical technologies. Primary care plays a pivotal role in protecting kidney health, particularly in LICs and LMICs. The limited global nephrology workforce, with a median prevalence of only 11.8 nephrologists per million population, and an 80-fold disparity between LICs and HICs, is inadequate to detect and manage the vast majority of CKD.23 As with other chronic diseases, primary care clinicians and frontline health workers are essential for the early detection and management of CKD.49 Testing must be affordable, simple, and practical. In resource-limited settings, point-of-care creatinine testing and urine dipsticks are especially useful.31 Educational efforts targeting primary care clinicians are crucial to integrating CKD detection into routine clinical practice, despite time and resource constraints.50 51 52 Additionally, automated clinical decision support systems can leverage electronic health records to identify individuals with CKD or those at high risk, then prompt clinicians with appropriate actions (Fig 228).

Currently, few countries have CKD registries, limiting the ability to accurately quantify disease burden and advocate for resources. Knowledge of the CKD burden is essential for prioritising kidney health and developing strategies that progressively expand to encompass the full spectrum of kidney care.53 A global survey revealed only one-quarter of countries (41/162) had a national CKD strategy, and fewer than one-third (48/162) recognised CKD as a public health priority.23 Recognition by the WHO that CKD is a major contributor to non-communicable disease mortality would be a crucial step forward. It would help raise awareness, enhance local surveillance and monitoring, support the implementation of clinical practice guidelines, and improve allocation of healthcare resources.2

Programmes for the early detection of CKD will require extensive coordination and active engagement from a wide range of stakeholders, including governments, healthcare systems, and insurers. International and national kidney organisations—such as the International Society of Nephrology—are already advocating to the WHO and individual governments for greater prioritisation of kidney disease. We must continue this work through collaborative efforts to streamline the planning and implementation of early detection programmes. Integration with existing community interventions (eg, cardiovascular disease prevention initiatives) in both LICs and HICs can decrease costs and maximise efficiency by building on established infrastructures. Such programmes must be adapted to local contexts and can be delivered in a variety of settings, including general practice clinics, hospitals, regional or national healthcare facilities, and rural outreach initiatives. Depending on local regulations and available resources, screening and case-finding can also occur outside conventional medical environments, for example, in town halls, churches, or markets. Community volunteers can also assist with these outreach and screening efforts.

In conjunction with changes in clinical practice to promote earlier detection of CKD, we must also focus on increasing public awareness of kidney disease risk and promoting health education. Such campaigns should be aimed at both the general public and patients, with the goal of fostering greater awareness and self-empowerment. General population awareness of CKD is poor: nine of ten people with the condition are unaware that they are affected.54 Furthermore, kidney disease is missing from mainstream media. One analysis of lay press coverage showed that kidney disease was discussed 11 times less frequently than would be expected based on its actual contribution to mortality.55 A number of national and international organisations have developed public-facing quizzes to help individuals assess their risk of kidney disease. These initiatives are supported by regional studies showing that socially vulnerable patients with hypertension often do not understand their kidney health risks.21 56 57 58 Online and direct education for healthcare professionals can also help improve consumer health literacy. Awareness leads to increased patient activation, engagement, and shared decision-making. However, education around CKD must be nuanced—balancing the need for detection and risk stratification with the importance of informing and empowering, rather than frightening, individuals about the timing and extent of potential interventions (Box).4 58 Striking this balance will be critical for optimising self-efficacy and encouraging active involvement from patients, families and caregivers.

We call on all healthcare professionals to assess the kidney health of patients at risk of CKD. Concurrently, we must partner with public health organisations to raise awareness among the general population about the risk of kidney disease and empower at-risk individuals to proactively seek kidney health checks. To make meaningful progress, collaboration with healthcare systems, governments, and the WHO is essential to prioritise kidney disease and develop effective, efficient early detection programmes. Only through these efforts can we ensure that the paradigm-shifting benefits of lifestyle changes and pharmacological treatments are fully realised, leading to better kidney and overall health outcomes for people around the world.

All authors contributed equally to the conception, preparation, and editing of the manuscript. All authors approved the final version for publication and take responsibility for its accuracy and integrity.

All authors have disclosed no conflicts of interest.

The authors thank members of the World Kidney Day Joint Steering Committee, including Valerie A Luyckx, Marcello Tonelli, Ifeoma Ulasi, Vivekanand Jha, Marina Wainstein, Siddiq Anwar, Daniel O’Hara, Elliot K Tannor, Jorge Cerda, Elena Cervantes, and María Carlota González Bedat, for their invaluable feedback on this article.

This article was published in Kidney International (Vassalotti JA, Francis A, Soares Dos Santos AC Jr, et al. Are your kidneys Ok? Detect early to protect kidney health. Kidney International. 2025;107(3):370-377. https://dx.doi.org/10.1016/j.kint.2024.12.006) and reprinted concurrently in several journals. The articles cover identical concepts and wording, but vary in minor stylistic and spelling changes, detail, and length of manuscript in keeping with each journal’s style. Any of these versions may be used in citing this article.

This editorial received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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2. Luyckx VA, Tuttle KR, Abdellatif D, et al. Mind the gap in kidney care: translating what we know into what we do. Kidney Int 2024;105:406-17. Crossref

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5. GBD Chronic Kidney Disease Collaboration. Global, regional, and national burden of chronic kidney disease, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2020;395:709-33. Crossref

6. Cojuc-Konigsberg G, Guijosa A, Moscona-Nissan A, et al. Representation of low- and middle-income countries in CKD drug trials: a systematic review. Am J Kidney Dis 2025;85:55-66.e1. Crossref

7. Hsiao LL, Shah KM, Liew A, et al. Kidney health for all: preparedness for the unexpected in supporting the vulnerable. Kidney Int 2023;103:436-43. Crossref

8. Francis A, Harhay MN, Ong AC, et al. Chronic kidney disease and the global public health agenda: an international consensus. Nat Rev Nephrol 2024;20:473-85. Crossref

9. Foreman KJ, Marquez N, Dolgert A, et al. Forecasting life expectancy, years of life lost, and all-cause and cause-specific mortality for 250 causes of death: reference and alternative scenarios for 2016-40 for 195 countries and territories. Lancet 2018;392:2052-90. Crossref

10. Viggiano D, Wagner CA, Martino G, et al. Mechanisms of cognitive dysfunction in CKD. Nat Rev Nephrol 2020;16:452-69. Crossref

11. Chen K, Didsbury M, van Zwieten A, et al. Neurocognitive and educational outcomes in children and adolescents with CKD: a systematic review and meta-analysis. Clin J Am Soc Nephrol 2018;13:387-97. Crossref

12. Francis A, Didsbury MS, van Zwieten A, et al. Quality of life of children and adolescents with chronic kidney disease: a cross-sectional study. Arch Dis Child 2019;104:134-40. Crossref

13. United States Renal Data System. 2023 USRDS Annual Data Report: epidemiology of kidney disease in the United States. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2023.

14. Liyanage T, Ninomiya T, Jha V, et al. Worldwide access to treatment for end-stage kidney disease: a systematic review. Lancet 2015;385:1975-82. Crossref

15. Bello AK, Levin A, Tonelli M, et al. Assessment of global kidney health care status. JAMA 2017;317:1864-81. Crossref

16. Ortiz A, Wanner C, Gansevoort R; ERA Council. Chronic kidney disease as cardiovascular risk factor in routine clinical practice: a position statement by the Council of the European Renal Association. Nephrol Dial Transplant 2023;38:527-31. Crossref

17. Johnson RJ, Wesseling C, Newman LS. Chronic kidney disease of unknown cause in agricultural communities. N Engl J Med 2019;380:1843-52. Crossref

18. McCulloch M, Luyckx VA, Cullis B, et al. Challenges of access to kidney care for children in low-resource settings. Nat Rev Nephrol 2021;17:33-45. Crossref

19. Stanifer JW, Muiru A, Jafar TH, Patel UD. Chronic kidney disease in low- and middle-income countries. Nephrol Dial Transplant 2016;31:868-74. Crossref

20. Levey AS, Schoolwerth AC, Burrows NR, et al. Comprehensive public health strategies for preventing the development, progression, and complications of CKD: report of an expert panel convened by the Centers for Disease Control and Prevention. Am J Kidney Dis 2009;53:522-35. Crossref

21. Internation Society of Nephrology. World Kidney Day 2025. Available from: https://www.worldkidneyday.org/about-kidney-health/. Accessed 11 Jan 2025.

22. Lloyd-Jones DM, Allen NB, Anderson CA, et al. Life's Essential 8: updating and enhancing the American Heart Association's Construct of Cardiovascular Health: a presidential advisory from the American Heart Association. Circulation. 2022;146:e18-43. Crossref

23. Bello AK, Okpechi IG, Levin A, et al. An update on the global disparities in kidney disease burden and care across world countries and regions. Lancet Glob Health 2024;12:e382-95. Crossref

24. Ferrè S, Storfer-Isser A, Kinderknecht K, et al. Fulfillment and validity of the kidney health evaluation measure for people with diabetes. Mayo Clin Proc Innov Qual Outcomes 2023;7:382-91. Crossref

25. Alfego D, Ennis J, Gillespie B, et al. Chronic kidney disease testing among at-risk adults in the U.S. remains low: real-world evidence from a national laboratory database. Diabetes Care 2021;44:2025-32. Crossref

26. Stempniewicz N, Vassalotti JA, Cuddeback JK, et al. Chronic kidney disease testing among primary care patients with type 2 diabetes across 24 U.S. health care organizations. Diabetes Care 2021;44:2000-9. Crossref

27. Kushner PR, DeMeis J, Stevens P, Gjurovic AM, Malvolti E, Tangri N. Patient and clinician perspectives: to create a better future for chronic kidney disease, we need to talk about our kidneys. Adv Ther 2024;41:1318-24. Crossref

28. Shlipak MG, Tummalapalli SL, Boulware LE, et al. The case for early identification and intervention of chronic kidney disease: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. Kidney Int 2021;99:34-47. Crossref

29. Farrell DR, Vassalotti JA. Screening, identifying, and treating chronic kidney disease: why, who, when, how, and what? BMC Nephrol 2024;25:34. Crossref

30. Tuttle KR. CKD screening for better kidney health: why? who? how? when? Nephrol Dial Transplant 2024;39:1537-9. Crossref

31. Tummalapalli SL, Shlipak MG, Damster S, et al. Availability and affordability of kidney health laboratory tests around the globe. Am J Nephrol 2020;51:959-65. Crossref

32. Seegmiller JC, Bachmann LM. Urine albumin measurements in clinical diagnostics. Clin Chem 2024;70:382-91. Crossref

33. van Mil D, Kieneker LM, Heerspink HJ, Gansevoort RT. Screening for chronic kidney disease: change of perspective and novel developments. Curr Opin Nephrol Hypertens 2024;33:583-92. Crossref

34. Sacks DB, Arnold M, Bakris GL, et al. Guidelines and recommendations for laboratory analysis in the diagnosis and management of diabetes mellitus. Clin Chem 2023;69:808-68. Crossref

35. Tonelli M, Dickinson JA. Early detection of CKD: implications for low-income, middle-income, and high-income countries. J Am Soc Nephrol 2020;31:1931-40. Crossref

36. Moreno JA, Martín-Cleary C, Gutiérrez E, et al. Haematuria: the forgotten CKD factor? Nephrol Dial Transplant 2012;27:28-34. Crossref

37. Franceschini N, Feldman DL, Berg JS, et al. Advancing genetic testing in kidney diseases: report from a National Kidney Foundation Working Group. Am J Kidney Dis 2024;84:751-66. Crossref

38. Mjøen G, Hallan S, Hartmann A, et al. Long-term risks for kidney donors. Kidney Int 2014;86:162-7. Crossref

39. Wilson JM, Jungner G, World Health Organization. Public Health Papers. Principles and practice of screening for disease. World Health Organization, 1968. Available from: https://apps.who.int/iris/handle/10665/37650. Accessed 11 Apr 2025.

40. Francis A, Abdul Hafidz MI, Ekrikpo UE, et al. Barriers to accessing essential medicines for kidney disease in low- and lower middle-income countries. Kidney Int 2022;102:969-73. Crossref

41. Baigent C, Emberson J, Haynes R, et al. Impact of diabetes on the effects of sodium glucose co-transporter-2 inhibitors on kidney outcomes: collaborative meta-analysis of large placebo-controlled trials. Lancet 2022;400:1788-801. Crossref

42. Vart P, Vaduganathan M, Jongs N, et al. Estimated lifetime benefit of combined RAAS and SGLT2 inhibitor therapy in patients with albuminuric CKD without diabetes. Clin J Am Soc Nephrol 2022;17:1754-62. Crossref

43. Vanholder R, Annemans L, Brown E, et al. Reducing the costs of chronic kidney disease while delivering quality health care: a call to action. Nat Rev Nephrol 2017;13:393-409. Crossref

44. Berman-Parks N, Berman-Parks I, Gómez-Ruíz IA, Ardavin-Ituarte JM, Piccoli GB. Combining patient care and environmental protection: a pilot program recycling polyvinyl chloride from automated peritoneal dialysis waste. Kidney Int Rep 2024;9:1908-11. Crossref

45. Essue BM, Laba M, Knaul F, et al. Economic burden of chronic ill health and injuries for households in low- and middle-income countries. In: Jamison DT, Gelband H, Horton S, editors. Disease Control Priorities: Improving Health and Reducing Poverty. Washington (DC): The International Bank for Reconstruction and Development/The World Bank; 2017. Crossref

46. Yeo SC, Wang H, Ang YG, Lim CK, Ooi XY. Cost-effectiveness of screening for chronic kidney disease in the general adult population: a systematic review. Clin Kidney J 2024;17:sfad137. Crossref

47. Cusick MM, Tisdale RL, Chertow GM, Owens DK, Goldhaber-Fiebert JD. Population-wide screening for chronic kidney disease: a cost-effectiveness analysis. Ann Intern Med 2023;176:788-97. Crossref

48. Yadla M, John P, Fong VK, Anandh U. Ethical issues related to early screening programs in low resource settings. Kidney Int Rep 2024;9:2315-9. Crossref

49. Szczech LA, Stewart RC, Su HL, et al. Primary care detection of chronic kidney disease in adults with type-2 diabetes: the ADD-CKD Study (awareness, detection and drug therapy in type 2 diabetes and chronic kidney disease). PLoS One 2014;9:e110535. Crossref

50. Vassalotti JA, Centor R, Turner BJ, et al. Practical approach to detection and management of chronic kidney disease for the primary care clinician. Am J Med 2016;129:153-62.e7. Crossref

51. Thavarajah S, Knicely DH, Choi MJ. CKD for primary care practitioners: can we cut to the chase without too many shortcuts? Am J Kidney Dis 2016;67:826-9. Crossref

52. Vassalotti JA, Boucree SC. Integrating CKD into US primary care: bridging the knowledge and implementation gaps. Kidney Int Rep 2022;7:389-96. Crossref

53. Luyckx VA, Moosa MR. Priority setting as an ethical imperative in managing global dialysis access and improving kidney care. Semin Nephrol 2021;41:230-41. Crossref

54. US Centers for Disease Control and Prevention. Chronic kidney disease in the United States, 2023. Available from: https://www.cdc.gov/kidney-disease/php/data-research/index.html. Accessed 11 Jan 2025.

55. Dattani S, Spooner F, Ritchie H, Roser M. Causes of death. 2023. Available from: https://ourworldindata.org/causes-of-death. Accessed 11 Jan 2025.

56. Boulware LE, Carson KA, Troll MU, Powe NR, Cooper LA. Perceived susceptibility to chronic kidney disease among high-risk patients seen in primary care practices. J Gen Intern Med 2009;24:1123-9. Crossref

57. National Kidney Foundation. Kidney Quiz 2024. Available from: https://www.kidney.org/kidney-quiz/. Accessed 11 Jan 2025. Crossref

58. Tuot DS, Crowley ST, Katz LA, et al. Usability testing of the kidney score platform to enhance communication about kidney disease in primary care settings: qualitative think-aloud study. JMIR Form Res 2022;6:e40001. Crossref

Gastric and oesophageal cancers are both highly lethal but often overlooked diseases in Hong Kong. During the early stages of these cancers, patients are typically asymptomatic or exhibit only mild symptoms, leading to late diagnoses, delayed treatment, and poor prognoses. Although the prevalences of both cancers have declined in recent decades, coinciding with a reduction in the number of smokers,1 the likelihood of advanced metastasis at diagnosis and the associated mortality rates remain substantially higher relative to cancers such as prostate cancer.2 In 2021, 1306 cases of gastric cancer were newly diagnosed1; 631 patients succumbed to the disease in the same year, making it the sixth leading cause of cancer-related deaths in Hong Kong.1 From 2017 to 2021, the mortality-to-incidence ratios were 0.48 for men and 0.44 for women, reflecting a low 5-year survival rate.3 Although the prevalence of oesophageal cancer has declined in recent years, its mortality rate remains high.4 In 2021, 397 new cases of oesophageal cancer were diagnosed, and 299 deaths were reported in the same year.5 By 2021, it was the tenth leading cause of cancer-related deaths in Hong Kong.6

Among all gastrointestinal (GI) cancers, population screening in Hong Kong is only available for colorectal cancer (via the faecal immunochemical test). Due to the comparatively lower incidences of upper GI cancers, no formal screening programme currently exists. Diagnosis of these cancers mainly relies on opportunistic endoscopic screening in patients who present with non-localising symptoms. Non-invasive screening tools for upper GI cancers are currently lacking, despite some promising modalities under investigation. A recent study validated a scoring system that incorporates weighted risk factors based on their contribution to gastric cancer development.7 However, in Hong Kong’s public hospitals, oesophagogastroduodenoscopy (OGD) is primarily indicated for suspected or confirmed cases of peptic ulcer disease, GI bleeding, oesophageal or gastric cancer; it is also indicated for symptoms such as indigestion, acid reflux, or dysphagia.8 By the time diagnostic symptoms appear, most patients display advanced cancer beyond curative treatment, resulting in poor survival outcomes. Thus, a comprehensive screening model for upper GI cancers is urgently needed.

Screening approaches for gastric and oesophageal cancers considerably vary worldwide, shaped by regional factors such as cancer prevalence, healthcare infrastructure, and medical policies. The local incidences of these cancers serve as the main determinants of screening strategies.

In regions with higher incidence rates, broader population-based screening is often utilised. In Japan, population-based screening is conducted using endoscopic and radiographic examinations, as outlined in the Japanese Guidelines for Gastric Cancer Screening.9 Endoscopic screening was added in 2014, despite challenges related to accessibility.9 Similarly, in Korea, biennial screening for gastric cancer is conducted among individuals aged >40 years10 via barium swallow, computed tomography, or endoscopy.11 In China where gastric cancer is also prevalent, screening strategies focus on highrisk populations through endoscopic examinations and serum pepsinogen testing12; high-risk groups are identified based on geographical prevalence.12 Regarding oesophageal cancer, similar targeted approaches are implemented. In regions with high rates of oesophageal squamous cell carcinoma, such as the Taihang Mountain range in China, population-based screening includes endoscopic examinations and cytology testing.13

Hong Kong, exhibiting comparatively lower incidences of both gastric and oesophageal cancers, highlights the limitations of a one-size-fits-all approach to cancer screening. A microsimulation model projecting population-wide gastric cancer screening in low-prevalence regions, such as the US, indicated a cost per quality-adjusted life year exceeding US$100 000, suggesting that such an approach is economically inefficient.14 Therefore, opportunistic screening focused on high-risk individuals is considered a more cost-effective strategy in these settings.

Countries where the incidence of gastric cancer is lower (eg, the US, the UK, and Singapore) do not implement routine population-wide screening programmes. Screening in these regions is more selective, targeting high-risk individuals, such as those with a family history of gastric cancer or carriers of Helicobacter pylori. In the US, targeted oesophageal cancer screening is recommended for individuals with Barrett’s oesophagus, given their increased risk of oesophageal adenocarcinoma.15 The frequency of endoscopic surveillance is determined by the severity of dysplasia identified in Barrett’s oesophagus.15 Medium-incidence countries have demonstrated potential benefits from targeting specific high-risk populations, often based on age.16

This variability in screening protocols underscores the need for region-specific strategies that consider local disease prevalence, healthcare infrastructure, and socio-economic factors.

Rather than assessing the risk of each cancer individually, a combined gastroesophageal risk prediction model offers a comprehensive assessment of the overall risk for developing upper GI cancers. This approach directly informs the need for OGD, providing clinicians with an objective framework to identify and prioritise patients who would benefit most from endoscopic evaluation. Only one combined gastroesophageal cancer risk prediction model has been developed for the general population.17 Although this model demonstrates relatively high discriminatory capability, as validated by two separate large-cohort studies,17 18 it may not be directly applicable to clinical practice in Hong Kong for the following reasons.

First, the model was developed and validated in the UK, primarily using data from a Western population.17 18 Variations in cancer risk factors among ethnic groups are well documented; for example, the incidence of gastric cancer is higher in Asian populations due to gene-environment interactions.19 Therefore, the hazard ratios for risk factors derived from the UK population may not be suitable for the Southern Chinese population in Hong Kong. A model tailored to risk factors directly relevant to the Hong Kong population would likely provide greater discriminatory capability and clinical utility.

Second, the existing model heavily relies on the presence of ‘alarm symptoms’ for gastroesophageal cancer reported by patients to their general practitioners, such as dysphagia, abdominal pain, and appetite loss. Although these symptoms are sensitive indicators of cancer, their use as primary predictors limits the model’s effectiveness in identifying patients at elevated risk during the early stages of cancer progression. Early-stage cancers are often asymptomatic or associated with subtle symptoms that may not be clinically apparent. The incorporation of readily available and objectively measurable factors, such as demographic data and medical history, into the model could facilitate more effective stratification of patients requiring OGD screening, enabling earlier medical intervention before substantial disease progression.

The high mortality-to-incidence ratios associated with gastric and oesophageal cancers represent considerable public health challenges in Hong Kong. However, the current methods for cancer risk stratification and patient selection for further investigation remain inadequate. The use of de-identified clinical data from patients previously diagnosed with oesophageal and gastric cancers, accessible through the Clinical Data Analysis and Reporting System of the Hospital Authority, would enable the development of a prediction model tailored to the Hong Kong population. The incorporation of such a prediction model into routine clinical practice could enhance the early detection of upper GI cancers, facilitate timely medical intervention, and improve treatment outcomes. This approach offers a promising strategy for reducing the mortality associated with upper GI cancers in Hong Kong.

Concept or design: All authors.
Acquisition of data: CWK Hui, JNF Lam, KH Man.
Analysis or interpretation of data: CWK Hui, JNF Lam, KH Man.
Drafting of the manuscript: All authors.
Critical revision of the manuscript for important intellectual content: All authors.

All authors had full access to the data, contributed to the study, approved the final version for publication, and take responsibility for its accuracy and integrity.

All authors have disclosed no conflicts of interest.

This editorial received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. Centre for Health Protection, Department of Health, Hong Kong SAR Government. Stomach cancer. 2024 Jan 12. Available from: https://www.chp.gov.hk/en/healthtopics/content/25/55.html. Accessed 11 Nov 2024.

2. Cancer Online Resource Hub, Hong Kong SAR Government. Prostate cancer. Available from: https://www.cancer.gov.hk/en/hong_kong_cancer/common_cancers_in_hong_kong/prostate_cancer.html. Accessed 7 Nov 2024.

3. Hospital Authority. Stomach cancer in 2021. 2023. Available from: https://www3.ha.org.hk/cancereg/pdf/factsheet/2021/stomach_2021.pdf. Accessed 10 Nov 2024.

4. Wang L, Du J, Sun H. Evolution of esophageal cancer incidence patterns in Hong Kong, 1992-2021: an age-period- cohort and decomposition analysis. Int J Public Health 2024;69:1607315. Crossref

5. Centre for Health Protection, Department of Health, Hong Kong SAR Government. Oesophageal cancer. 2024 Jan 12. Available from: https://www.chp.gov.hk/en/healthtopics/content/25/50.html. Accessed 20 Nov 2024.

6. Hong Kong Anti-Cancer Society. Latest cancer statistics. Available from: https://www.hkacs.org.hk/en/medicalnews.php?id=213. Accessed 7 Nov 2024.

7. Wong MC, Leung EY, Yau ST, et al. Prediction algorithm for gastric cancer in a general population: a validation study. Cancer Med 2023;12:20544-53. Crossref

8. Coordinating Committee in Internal Medicine, Hospital Authority. Patient information on oesophagogastroduodenoscopy (OGD). 2023 Nov 30. Available from: https://www.ekg.org.hk/pilic/public/IM_PILIC/IM_OGD_0049_eng.pdf. Accessed 9 Nov 2024.

9. Yashima K, Shabana M, Kurumi H, Kawaguchi K, Isomoto H. Gastric cancer screening in Japan: a narrative review. J Clin Med 2022;11:4337. Crossref

10. Ryu JE, Choi E, Lee K, et al. Trends in the performance of the Korean National Cancer Screening Program for Gastric Cancer from 2007 to 2016. Cancer Res Treat 2022;54:842-9. Crossref

11. Kim TH, Kim IH, Kang SJ, et al. Korean Practice Guidelines for Gastric Cancer 2022: an evidence-based, multidisciplinary approach. J Gastric Cancer 2023;23:3-106. Crossref

12. Fan X, Qin X, Zhang Y, et al. Screening for gastric cancer in China: advances, challenges and visions. Chin J Cancer Res 2021;33:168-80. Crossref

13. Zheng Y, Niu X, Wei Q, Li Y, Li L, Zhao J. Familial esophageal cancer in Taihang Mountain, China: an era of personalized medicine based on family and population perspective. Cell Transplant 2022;31:9636897221129174. Crossref

14. Lee YT. Gastric cancer screening. J Soc Physicians Hong Kong 2023;15:13-5.

15. Fitzgerald RC, di Pietro M, Ragunath K, et al. British Society of Gastroenterology guidelines on the diagnosis and management of Barrett’s oesophagus. Gut 2014;63:7-42. Crossref

16. Dan YY, So JB, Yeoh KG. Endoscopic screening for gastric cancer. Clin Gastroenterol Hepatol 2006;4:709-16. Crossref

17. Hippisley-Cox J, Coupland C. Identifying patients with suspected gastro-oesophageal cancer in primary care: derivation and validation of an algorithm. Br J Gen Pract 2011;61:e707-14. Crossref

18. Collins GS, Altman DG. Identifying patients with undetected gastro-oesophageal cancer in primary care: external validation of QCancer® (Gastro-Oesophageal). Eur J Cancer 2013;49:1040-8. Crossref

19. Ashktorab H, Kupfer SS, Brim H, Carethers JM. Racial disparity in gastrointestinal cancer risk. Gastroenterol 2017;153:910-23. Crossref

In a fair and equitable society, individuals with disabilities should have access to the same educational opportunities as those who are not so affected. In Hong Kong, the principle of equal opportunities in education is given legal effect requiring training institutions to provide ‘reasonable accommodations’ to address the educational needs of disabled individuals.1

Tension may arise, however, when a disabled medical student or trainee doctor undertakes educational activities or assessments that exceed their physical and/or mental capabilities due to their disability, unless substantial accommodations are implemented. The prioritisation of patient welfare in medical ethics, placing it ‘above and beyond considerations of personal interests and private gains’ may give rise to a perceived conflict between the ideal of equal opportunities and the responsibility of training institution to ensure that professional standards and patient safety are not compromised.2

Should a medical student with impaired hearing be permitted to use hearing aids during lectures? Should a trainee with colour vision deficiency be provided specially annotated histological micrographs during examinations? What about a student with an anxiety disorder who requests extra time for a clinical competency test?

Uncommon in the past, these questions have been raised with increasing frequency in recent years. The traditional view that professional training requirements should be undaunted and taking precedence over all other considerations no longer holds, as it is now widely recognised that a diverse healthcare workforce, inclusive of disabled individuals, contributes to better overall patient care.3 Even long-standing and expressly stipulated regulations could be challenged if not justifiable on the grounds of non-discrimination. In the United Kingdom August this year, legal action was successfully brought against the Royal College of General Practitioners for failing to provide a disabled trainee with ‘reasonable adjustments,’ including additional time for examinations.4 A more nuanced and balanced approach is clearly needed.

In response, the Hong Kong Academy of Medicine and the medical faculties of The University of Hong Kong and The Chinese University of Hong Kong recently issued a consensus statement on supporting students and trainees with disabilities.5 This joint statement is the product of discussions held under the auspices of a quadripartite platform established in 2023, under a memorandum of understanding involving the aforementioned three institutions and the Hospital Authority.6 (The latter is not a party to the joint statement because it primarily functions as an employer, rather than an educational institution.)

The result is a principles-based, high-level policy instrument setting out the parties’ commitment to equal opportunities and their legal obligations to provide disabled individuals in training with ‘reasonable accommodations.’ To uphold professional standards of practice and comply with relevant legal provisions, such accommodations should not impose an ‘unjustifiable hardship’ on the institution, such as when the accommodation compromises the standard or level of professional education and training.1 An emphasis is placed on procedural fairness, transparency, and accountability; every request for special accommodation must be assessed on a case-by-case basis, considering the unique circumstances presented. ‘Blanket policies’ regarding accommodation are discouraged, and an appeal mechanism must be in place. The two medical schools and the 15 constituent colleges of the Hong Kong Academy of Medicine are required to establish their own internal procedures for assessing requests, given the wide range of learning objectives, curriculum designs, and assessment methodologies involved. A common template serves as a reference to promote intra- and inter-institutional consistency.

The real-world implementation of this policy will depend largely on the nature and scope of the ‘reasonable accommodations’ identified in each case, subject to the broad legal definition of ‘disability’ which educational establishments must carefully consider. The Code of Practice on Education issued by the Equal Opportunities Commission provides helpful guidance on this matter, including guidance for determining what constitutes ‘unjustifiable hardship’, which, if present, may exempt educational establishments from liability for not providing an accommodation.1 The overarching principle is that requests for special accommodations must be considered, but training institutions are obligated only to provide accommodations which are reasonable and do not constitute ‘unjustifiable hardship’ for the institution, as determined on a case-by-case basis.

Going forward, several outstanding issues require examination by the quadripartite platform. First, disabled individuals often face barriers when applying for admission to training programmes. Institutions must ensure that their admission procedures do not discriminate against such individuals. Second, rather than relying on a reactive approach to addressing requests for accommodation, proactive mechanisms could be developed to identify and support disabled individuals at an early stage. Third, it remains unclear whether and under what circumstances a disabled individual who fails to meet the required professional standards due to disabilities, despite the best available accommodations, should be referred to the ‘fitness to practise’ procedures of the two medical schools or the Health Committee of the Medical Council of Hong Kong for further assessment. Finally, it is common knowledge that a disabled individual may achieve and maintain clinical competency in specific areas of practice, regardless of incompetency in others.3 Whether qualifying examinations should continue to be based on the premise that all medical students must achieve the same catalogue of clinical competencies, regardless of their intended career paths, and whether a regulatory mechanism should be introduced for granting conditional registrations limited to a specified and restricted scope of practice are questions deserving of our attention.

The author contributed to the editorial, approved the final version for publication, and takes responsibility for its accuracy and integrity.

The author has disclosed no conflicts of interest.

This editorial received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

1. Equal Opportunities Commission. Disability Discrimination Ordinance, Code of Practice on Education. Available from: https://www.eoc.org.hk/eoc/Upload/cop/ddo/cop_edu_e.htm. Accessed 19 Nov 2024.

2. The Medical Council of Hong Kong. Hong Kong Doctors (2017). Available from: https://www.mchk.org.hk/english/publications/files/HKDoctors.pdf. Accessed 19 Nov 2024.

3. Snashall D. Doctors with disabilities: licensed to practice? Clin Med (Lond) 2009;9:315-9. Crossref

4. Limb M. RCGP’s exam policy was unlawful, says landmark ruling in favour of doctors with disabilities. BMJ 2024;386:q1892. Crossref

5. Consensus Statement issued by the Hong Kong Academy of Medicine (“HKAM”), the Faculty of Medicine of The Chinese University of Hong Kong (“CUMed”) and the LKS Faculty of Medicine of The University of Hong Kong (“HKUMed”) with respect to the education and training of medical students and specialist trainees requiring special accommodation due to disability or special educational needs (“SENs”). Available from: https://www.hkam.org.hk/sites/default/files/2024-12/2024 Consensus Statement re SEN with HKU and CUHK.pdf. Accessed 18 Dec 2024.

6. Hong Kong Academy of Medicine, CU Medicine, HKUMed, and Hospital Authority forge quadripartite collaboration on healthcare education with memorandum of Understanding. Press release. Available from: https:// www.hkam.org.hk/sites/default/files/PDFs/2023/Press%20Release%20-%20HKAM%20Quadripartite%20MEC%20-%20MOU%20Signing%2020231127%20(clean)_ENG.pdf?v=1729296000078. Accessed 17 Nov 2024.